A 42-year-old patient is 3 days post-op from abdominal cholecystectomy. She is currently taking only antibiotics and hydrocodone. Today she complains of left calf pain just below the knee and states it is swollen, warm, and painful to touch. She denies other symptoms, significant history, or allergies.
- Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
- In SOAP format, list:
- Pertinent positive and negative information
- Differential and working diagnosis
- Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
- Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.